Guadalupe Valley Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed gloves during incontinent care for Resident #2. This failure could place residents at risk of cross contamination and infections.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1of 5 residents (Residents #1) reviewed for resident assessments. The Facility failed to ensure Resident #1's active diagnosis of repeated falls (two or more falls within a 12-month period) was reflected on the annual MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents who had the right to reside received services in the facility with reasonable accommodation of resident needs and preferences for 3 residents (Residents #6, #14 and #44) of 32 residents reviewed. 1. The facility failed to ensure Resident #6's call light was within reach. 2. The facility failed to ensure Resident #14's call light was within reach. 3. The facility failed to ensure Resident #44's call light was within reach. This facility failure could place residents at risk of not having a way to call for help or assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure all open items being stored in the walk-in refrigerator were labeled and dated with the use by date. The facility failed to ensure all open items being stored in the reach-in cooler were labeled and dated with the use by dateThe facility failed to take the temperatures of all foods served to residents. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 10 rooms (room [ROOM NUMBER]) and 1 of 3 shower rooms (#600 hall). The facility failed to ensure the vent that had excessive dust collected in the return vent in room [ROOM NUMBER] was cleaned. The facility failed to ensure a shower room on #600 hall was cleaned after use of a shower chair with feces, a bag with soiled towels, and a bag with a soiled brief. These failures could place residents at risk for respiratory illness and the spread infections and or diseases.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 2 of 32 residents (Residents #4 and #107) reviewed for resident assessments. 1. The facility failed to ensure Resident #4's therapeutic diet was accurately reflected on her Quarterly MDS assessment dated [DATE]. 2. The facility failed to ensure Resident #107's Bipap was accurately reflected on her quarterly MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 32 residents ( residents #14 and #107) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure a care plan was developed to address Resident #14's fall interventions. 2. The facility failed to ensure a care plan was developed to address Resident #107's indwelling urinary catheter leg strap. This failure could place residents at risk of not receiving the type of care required and result in unmet needs.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent with bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident of 2 residents (Resident #107) reviewed for catheter care. The facility failed to ensure Resident #107 had a leg strap to secure her indwelling urinary catheter tubing. This deficient practice could place residents' risk of complications and infection from movement at the insertion site.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 5 residents (Resident # 77) reviewed for oxygen therapy. The facility failed to replace or clean dirty and dusty oxygen filters in Resident #77's oxygen concentrator. This deficient practice could place residents at risk of respiratory infection and difficulty breathing.

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans, in that. The facility failed to update Resident #1's care plan to reflect Resident #1 was attempting to eat non-food items. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving appropriate care.

Inspectors wroteBased on interviews, observation, and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 6 residents (Resident #1) reviewed for consents for accurate medical records. 1. The facility failed to ensure that there was a doctor order on 01/21/2026 in Resident #1's electronic medical record to reflect that 1 enema (a procedure in which liquid or gas is injected into the rectum, typically to expel its contents) was given to Resident #1. 2. The facility failed to ensure the bathing documentation for Resident #1, accessed on 02/22/2026, was complete and included Resident #1 had a bed bath on 02/17/2026, resident refused on 02/16/2026, and bathing was not applicable on 02/13/2026. These failures could place residents at risk for inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 8 of 17 residents (Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) and 4 of 6 medication carts (MC #1, MC #2, MC #4 and MC #6) reviewed for pharmaceutical services. 1. The facility failed to ensure discontinued/expired medications were removed from the medication carts on (4) occasions.2. The facility failed to ensure the administration and count of controlled substances were reconciled on (3) occasions.3. The facility failed to ensure counts of controlled medications were completed/signed for on (28) occasions. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater for 1 of 5 residents (Resident #12). The facility had a medication error rate of 45% based on 5 errors out of 11 opportunities. LVN D failed to administer medications as ordered to Resident #12 by administering Gabapentin (for neuropathy), Cyclobenzaprine (for pain), Colace (for constipation), Carboxymethylcellulose Sodium ophthalmic gel (dry eyes), and Rosuvastatin (for high cholesterol) 2 hours and 12 minutes before the scheduled time. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 residents (Resident #11) reviewed for medication labeling. The facility failed to ensure medications were correctly labeled. These deficient practices could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 2 residents (Resident #1) reviewed for medical records:The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 8/2/25, 8/3/25, 8/5/25, 8/8/25, 8/13/25, 8/14/25, and 8/16/25. These failures could place residents at risk for missed treatments and care which could result in the deterioration of the wound and/or development of an infection.

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's provider of his change in condition when the Wound Care Nurse identified the resident developed a Stage 2 pressure ulcer on 8/6/25. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans:The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's pressure wound, refusals for offloading and repositioning and wound care treatments. This failure could place residents at risk of not having their needs and preferences met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 1 resident (Resident #2), in the facility reviewed for accidents, in that:The facility failed to ensure Resident # 2 did not have disposable razors in his room. This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (Wound Care Nurse) reviewed for competent nursing care. The facility failed to ensure the Wound Care Nurse was aware of notification of changes to the RN Unit Manager or designee per facility policy when she identified Resident #1 with a Stage 2 pressure ulcer. These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Residents #12) reviewed for infection control. The facility failed to ensure LVN D followed proper infection control practices during medication administration on 9/26/25. This deficient practice could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that: CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 06/05/2025. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #6) reviewed for infection control, in that: While providing incontinent care for Resident #6, CNA A did not change her gloves or wash her hands after cleaning the resident and before touching the clean draw sheet and clean brief on 06/05/2025. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 1 shower room (300 hall) and 5 of 5 resident rooms (#312, #314, #315, #316 and #506) whose rooms were observed for housekeeping services. 1. Nursing staff failed to clean and sanitize the 300-hall shower room after each resident shower. 2. The facility failed to ensure Resident Rooms #312, #314, #315, #316 and #506 were thoroughly cleaned and sanitized. These deficient practices could place any residents at risk of living in an unclean and unsanitary environment and result in feelings of dissatisfaction.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 4 shower rooms (300-hall shower room) and in 2 of 2 Resident rooms (#308 and #516) observed for safety hazards. 1. Nursing staff failed to ensure razors were disposed of after used in the 300-hall shower room and to ensure an oxygen tank was returned to a resident room. 2. Nursing staff failed to ensure a razor was secured and not left in resident room [ROOM NUMBER]. 3. Nursing staff failed to ensure multiple sharp devices/scissors were secured and not left in resident room [ROOM NUMBER]. These deficient practices could affect resident who had access to sharps materials and could result in an avoidable accident.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and handle, store, process, and transport linens to prevent the spread of infection for 2 of 5 resident halls (300-hall & 500-hall) and in 2 of 2 resident rooms (#308 and #506) reviewed for infection control. 1. A dirty linen barrel on 500-hall had dirty linen spilling over the edges and the lid was sitting approximately 2.5 inches above the barrel on top of the dirty linen. 2. Dirty towels with feces were left on the floor in the shower stall and there was a lump of feces on the floor in the 300-hall shower room. 3. There were drops of blood by bed B in room [ROOM NUMBER]. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 8 (Food Service Manager, Cook, Housekeeper, Maintenance Assistant, CNA B, CNA C, CNA D, and CNA E) of 29 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to Food Service Manager, Cook, Housekeeper, Maintenance Assistant, CNA B, CNA C, CNA D, and CNA E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on communications training for 3 of 29 employees (Cook, CNA B, and CNA D) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Cook, CNA B, and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on rights of the resident training for 4 of 29 employees (Food Service Manager, Cook, CNA B and CNA D) reviewed for training, in that: The facility failed to ensure effective rights of the resident training was provided to Food Service Manager, Cook, CNA B and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 4 (Cook, CNA C, CNA D, CNA E) of 29 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to Cook, CNA C, CNA D, CNA E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program training for 3 of 29 employees (Cook, CNA B and CNA D) reviewed for training, in that: The facility failed to ensure effective standards, policies, and procedures for an infection prevention and control program training was provided Cook, CNA B and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on behavioral health for 3 of 29 employees (Cook, Maintenance Assistant, CNA C) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided Cook, Maintenance Assistant, and CNA C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 Residents (Resident #8) who was observed for call light placement. The facility staff failed to ensure the call light was within reach for Resident #8. This failure could affect any resident and keep them from calling for help as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice, including but not limited to choose health care and providers of health care services consistent with his or her interests for 1 of 8 Residents (Resident #184) who was reviewed for services. The facility failed to meet and discuss with Resident #184, a new admission, Medicaid coverage and options for healthcare providers. This deficient practice could affect any resident who was a new admission to the facility and could result in residents not having the opportunity to participate in making decisions for health coverage and choosing health providers.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly or to commence a new form of treatment for 1 of 8 Residents (Resident #24) whose records were reviewed for medications. Nursing staff failed to contact Resident #24's PCP/NP on 1/14/25 when realizing medication insulin Toujeo was not available for night administration per physician orders. This deficient practice could affect any resident and could contribute to resident's not receiving medications per physician orders and result in a decline in condition.

Inspectors wroteBased on interview and record review the facility failed to provide routine and emergency drugs and biologicals for 1 of 8 Residents (Resident #24) whose records were reviewed for pharmacy services. LVN G failed to notify LVN H, the ADON or the DON that Resident #24's insulin medication, Toujeo was not delivered by the facility pharmacy and not available for administration on 1/14/25 to avoid further delay in delivery. Resident #24 did not receive his nighttime dose (80 units) of Toujeo insulin per physician orders. This deficient practice could affect any resident and could contribute to resident's not receiving medications per physician orders and result in a decline in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on abuse, neglect, exploitation, and misappropriation training for 2 of 29 employees (Cook, CNA D) reviewed for training, in that: The facility failed to ensure effective abuse, neglect, exploitation, and misappropriation training was provided to [NAME] and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on ethics training for 1 of 29 employees (Cook) reviewed for training, in that: The facility failed to ensure effective ethics training was provided [NAME] annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective in-service training for nurse aides on dementia for 1 of 5 nurse aides (CNA C) reviewed for training, in that: The facility failed to ensure effective dementia training was provided CNA C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident's #2) reviewed for respiratory care. The facility failed to ensure Resident #2's oxygen tubing and nasal cannula was handled by qualified staff. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 5 resident rooms (Resident #1), 1 of 5 hallways, 300 hall, and 1 of 1 medication cart. 1. The facility failed to ensure medications were not left at the bedside or on the floor for Resident #1. 2. The facility failed to ensure there were no medications found on the floor and the medication cart on the 300 hall was left unlocked and unattended. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident had the right to personal privacy for 1 of 2 residents (Resident #2) reviewed for dignity. Resident #2's bedroom door was not closed, and the privacy curtain was not completely drawn during catheter care on 8/29/24. This failure could affect residents by contributing to poor self-esteem, decreased self-worth, and quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 was provided catheter care according to professional standards; keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to trauma due to urethral tears or dislodging the catheter. This failure could place residents at risk for trauma resulting in diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 2 staff (CNA B and CNA C) reviewed for nurse aide competencies. 1. The facility failed to ensure CNA B performed perineal care for Resident #1, on 8/29/24, according to facility policy. 2. The facility failed to ensure CNA C performed catheter care for Resident #2, on 8/29/24, according to professional standards. This failure could place residents at risk for trauma and/or infection.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's vital signs were accurately documented in the EMR on 8/28/24. This failure could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA B followed proper infection control practices during perineal care for Resident #1 0n 8/29/24. 2. The facility failed to ensure CNA C followed proper infection control practices during catheter care for Resident #2 on 8/29/24. These failures could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's physician and notify, consistent with his or her authority, notify a resident's representative when there was an accident involving the resident when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: The facility failed to promptly notify Resident #1's physician and Resident #1's responsible party when Resident #1 exhibited right-sided facial drooping and edema and coolness to both hands on 4/20/24. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/24/24 at 5:23 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: On 4/20/24, upon the first onset of Resident #1 's symptoms, LVN A failed to recognize significant change of condition until the Resident #1's RP voiced concerns on 4/21/24. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/24/24 at 5:23 p.m. While the IJ was removed on 4/26/24 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure prompt notification of a resident's physician and responsible party. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 (Resident #40) out of 8 residents reviewed for MDS assessments in that: Resident #40's MDS assessment reflected her to be frequently incontinent of bladder when she was always incontinent of bladder. This failure could affect residents who required MDS assessments and result in lack of care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #85) of 12 residents observed during dining observations in that: Resident #85 was served a regular consistency diet when he was ordered a pureed. This failure could affect residents with eating and swallowing disorders and result in choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 25 residents (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for infection control in that: LVN A did not perform hand hygiene between passing the lunch meal trays of Resident #4, Resident #5, Resident #6, and Resident #7. This deficient practice could affect all residents and place them at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had evidence that all alleged violations involving abuse were thoroughly investigated, failed to take corrective action and prevent further potential abuse for 1 of 25 residents (Resident #1 and Resident #2) reviewed for abuse and neglect, in that: The facility did not conduct an investigation after being informed Resident #2 struck Resident #1 on the back of the head. This deficient practice could place residents at risk for abuse and placed them at risk for continued and/or unrecognized abuse, injury, and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 25 residents (Resident #3) reviewed for comprehensive care plans in that: Resident #3's care plan was not updated to reflect the aggressive behavior after he struck Resident #8 on 5/4/23. This deficient practice could affect all residents and place them at risk for not receiving appropriate treatment and services or activities: